1. Brain Injury Association of Maryland
"Dealing with Life, How to Deal with Substance Abuse/Misuse Following Brain Injury."
Brain Injury Association of Maryland
2017 Annual Conference
March23, 2017
Kara Keller
Jennifer Ehemann
Martin Kerrigan

2. Outcomes:
Participants will become familiar with incidence of brain injury and substance abuse/misuse
Participants will become familiar with why traditional forms of treatment do not always work with individuals with brain injuries.
Participants will learn about two different self-help groups in Maryland that address the co-occurring issues of substance abuse and brain injury.

3. What is Substance Abuse?
Substance abuse is defined by the American Heritage Dictionary as “the overindulgence in and dependence on an addictive substance, especially alcohol or a narcotic drug.”

4. What is Traumatic Brain Injury?
According to the Brain Injury Association of America, “An acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth.” 
Traumatic Brain Injury, or TBI, is defined by the Center for Disease Control and Prevention as “a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain.”

5. Relationship Between Brain Injury and Substance Abuse
There is a high correlation between substance abuse and brain injury.
According to one study, “between 36-51% of TBIs occurred when individuals were above the common legal limit for intoxication, while up to 78% of patients with TBI had consumed some alcohol at the time of their injury.”
Brain Injury vol.15, no.1 p

6. Why are People with Brain Injury at a High Risk for Substance Abuse?
Many times individuals with brain injuries have pre-existing substance abuse issues.
Often times, these pre-existing issues become exacerbated following the brain injury

7. Why are people with Brain Injury at a high risk for substance abuse?
The individual who suffered the brain injury may now have certain physical, cognitive, emotional, and behavioral limitations can prevent them from engaging in activities they previously enjoyed.
The cognitive and physical requirements for substance use are minimal.
The person with brain injury may also abuse substances in order to gain acceptance, especially socially.
The person with brain injury may begin using substances as a way to deal with physical pain.

8. Reporting of Substance Abuse
Many times substance abuse, in the individual with the brain injury, is not reported or not reported accurately.
Individuals with brain injury and their families do not want to seem like a poor candidate for rehabilitation.
Often times the person with the brain injury does not have an accurate picture of themselves and therefore is unaware of, or misinterprets their problem, or is completely unaware of it.

9. Contributing Factors to Substance Abuse in Brain Injury Survivors
Lack of structure leads to increased “down-time” which in turn leads to more opportunities to engage in substance abuse.
During rehabilitation, the patient is likely to interact with other brain injury survivors who have substance abuse problems. This provides an easy means to get substances as well as others to use the substances with.
Substance abuse is sometimes used as a coping strategy.

10. Detection of Substance Abuse
Once a person with a brain injury begins to use and abuse substances, it usually becomes much more obvious then before they suffered their brain injury.
The effects of drugs and alcohol are super-imposed in the brain injured patient.

11. Pre-injury Substance Abuse
Studies have shown that individuals who have a pre-morbid (pre-accident) history of substance abuse have often times already suffered brain damage through use of substances. These individuals also have a higher rate of memory impairment during the early stages of recovery.

12. Effects of Substance Abuse on a Person with a Brain Injury
Substance abuse can negatively impact the patient’s rehabilitation, decrease life satisfaction, increase depression, and increase the risk for seizure and re-injury

13. Impact of Substance Abuse on Recovery
Substance abuse has a negative impact on recovery.
Substance abuse effects outcomes such as length of stay, emotional well-being, and cognitive functioning.

14. Why is there such a High Incidence of Substance Abuse in Victims of Brain Injury?
The population that is most likely to suffer from TBI is young males (adolescent and young adult).
This is also the segment of the population that is most likely to engage in risky behaviors and to participate in substance abuse.

15. Socio-economic Status and Brain Injury
People from lower socio-economic status (SES) are less likely to receive proper rehabilitation and services after their brain injury.
People from this SES also have less access to effective means of treating their addictions.
There is often times more access and easier access to substances in lower SES areas.

16. Life Satisfaction and Substance Abuse in Individuals with Brain Injury
Life satisfaction is the way a person sees their life.
Research shows that substance abuse negatively effects satisfaction with life, in both individuals with brain injury and without brain injury.
According to one study, a history of substance abuse plays a much greater role in determining satisfaction with life than does injury related characteristics.

17. Treatment of Substance Abuse in People with Brain Injury
Traditional threats made to substance abusers usually do not have the same impact on substance abusers with brain injury.
Loss of employment often times does not mean much because the person with brain injury usually is either unemployed or under employed.

18. Why don’t traditional methods of substance abuse treatment work for individuals with brain injury?
The affects of brain injury often times mirror the impacts of someone that may be high or drunk.
Individuals may have impaired speech, may be unsteady on their feet, may have difficulty staying on topic, and so forth

19. Why don’t traditional methods of substance abuse treatment work for individuals with brain injury?
Individuals with brain injuries do not feel like they “fit in” and often have difficulty relating
12 step programs are often presented in an abstract manner.
The individual with a brain injury may not see their lives improving.

20. Treatment of substance abuse in persons with Brain Injury
Traditional programs and substance abuse intervention do not always work with individuals with brain injury, due to physical and cognitive limitations.
Several different alternatives to traditional forms of treatment for substance abuse have been developed.
The National Head Injury Foundation created a version of the 12 steps used in Alcoholics Anonymous for People with Traumatic Brain Injury.

21. When to address substance abuse in individuals with Brain Injury
It is suggested that during rehabilitation is a good time to address substance abuse.
This allows the rehabilitation professionals to address any substance abuse problems that may be present.
This is also a good time because the patient may be learning new coping skills and strategies that will help them in life.

22. Prevention of Substance Abuse in People with Brain Injury
Probably the best way to prevent substance abuse following head injury is to ensure sufficient meaningful relationships and activities to maximize quality of life.”
Judith Falconer. “Substance Abuse and brain Injury”
There needs to be more of an emphasis placed on identifying, treating, and preventing substance abuse in people with brain injury.

23. 2 Different Approaches in Maryland
“Fresh Start” meeting of Alcoholics/Narcotics Anonymous
“Changing Choices?” support group

24. Fresh Start Meeting of Alcoholics/Narcotics Anonymous
What: An open 12 step meeting geared to individuals living with brain injury and substance abuse
Where: Mary T. of Maryland, 820 Ritchie Highway Severna Park, Md 21146
When: Wednesday evenings, 6 p.m.   
For more information: Martin or Jennifer

25. Versions of the Twelve Steps for People with Brain Injuries
Versions of the Twelve Steps for People with Brain Injuries. From the National Head Injury Foundation (1988). Professional Council Substance Abuse Task Force. White Paper. Southborough, MA, NHIH, 1988.
Original Twelve Steps
1) We admitted we were powerless over alcohol; that our lives had become unmanageable. 
2) Came to believe that a Power greater than ourselves could restore us to sanity.
3) Made a decision to turn our will and our lives over to the care of God as we understood him.
4) Made a searching and fearless moral inventory of ourselves.
5) Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6) We are entirely ready to have God remove all these defects of character.
7) Humbly asked God to remove our shortcomings.
8) Made a list of all persons we had harmed and became willing to make amends to them all.
9) Made direct amends to such people wherever possible, except when to do so would injure them or others.
10) Continued to take personal inventory and when we were wrong, promptly admitted it.
11) Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 
12) Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in al of our affairs.
Version of the Twelve Steps of Alcoholics Anonymous for People With Traumatic Brain Injuries by William Peterman, BS, CADAC
1) Admit that if you drink or use drugs your life will be out of control. Admit that the use of alcohol and drugs after having a brain injury will make your life unmanageable.
2) You start to believe that someone can help you put your life in order. This someone could be God, an AA/NA group, counselor, sponsor, etc. 
3) You decide to get help from others or god. You open yourself up.
4) You make a complete list of the negative behaviors in your past and your current behavior problems. You also make a list of your positive behaviors. 
5) Meet with someone you trust and discuss what you wrote in step 4.
6) Become ready to sincerely try to change your negative behaviors.
7) Ask God for the strength to be a responsible person with responsible behaviors.
8) Make a list of people your negative behaviors have affected. Be ready to apologize or make things right with them.
9 )Contact these people. Apologize or make things right.
10) Continue to check yourself and your behaviors daily. Correct negative behaviors and improve them. If you hurt another person, apologize and make corrections.
11) Stop and think about how you are behaving several times each day. Are my behaviors positive? Am I being responsible? If not ask for help. Reward yourself when you are able to behave in a positive and responsible fashion. 
12) If you try to work these steps you will start to feel much better about yourself. Now it’s your turn to help others do the same. Helping others will make you feel even better. Continue to work these steps on a daily basis.

26. The “Fresh Start” group of Alcoholics/Narcotics Anonymous?
Has been in existence since 2006.
Allows for a non-threatening setting for individual’s with co-occurring substance abuse and brain injury to be part of a 12 step meeting.
Meetings consist of open share/topic, speaker, and literature meetings.

27. The “Fresh Start” Group of Alcoholics/Narcotics Anonymous?
Usually has approximately 20 individuals present.
Meeting secretary & coffee maker are individuals with brain injury.
Has resulted in approximately half of participants attending meetings out in the community.
Has resulted in long term sobriety for many of the individuals that attend the meeting.

29. “Changing Choices” Support Group
Started in 2016 to provide a place for individuals, loved ones, and families to go to explore substance abuse concerns and brain injury.
Created to “bridge the gap” between inpatient and outpatient.
Meeting is facilitated by two individuals, both familiar with brain injury and substance abuse.
It is not a 12 step meeting but more of a place to gain knowledge and to meet others living with similar difficulties.

30. “Changing Choices” Support Group
Allows for individuals to meet others who have gone or are going through similar experiences.
Meeting is open to individuals at all levels of recovery, from inpatient to individuals that are in the community and have been discharged from all services.
Helps to alleviate feelings of being “different” and unique.
Would like to have meeting grow to where survivors and their loved ones could split into two groups to help facilitate open conversation.

31. In Conclusion…
It is estimated that 9 of every 10 people that try getting clean and sober will eventually relapse.
Twelve step programs such as Alcoholics/Narcotics Anonymous have the highest success rate when it comes to helping individuals get and stay clean and sober.
Though the 12 steps seem abstract and can be difficult to interpret, they are actually rather simple when interpreted for what they were intended for and with some simple modifications can be used with individuals with cognitive deficits and limitations, as well as individuals with brain injuries.

32. In Conclusion…
For the individual with a brain injury getting and staying sober often proves to be a difficult task.
However, if the proper interventions are in place the success rate for individuals with brain injuries increases.
Some of these interventions include: rehabilitation staff educated in substance abuse, early substance abuse treatment, family understanding of substance abuse, a supportive and educated recovery community, individual acknowledgement of substance abuse as well as the desire to get sober on the behalf of the individual with the brain injury.

33. Questions

34. Jennifer Ehemann; jennifere@marytinc.com
Kara Keller;
Martin Kerrigan;